Event Notification Report for July 14, 2020

AGREEMENT STATE REPORT - GAUGE CRUSHED WITH SOURCE ROD EXTENDED

The following was received from the Illinois Emergency Management Agency (IEMA; the Agency) via email:

"At approximately 1530 CDT on July 14, 2020, the Agency was contacted by the RSO [(Radiation Safety Officer)] /owner of Construction & Geotechnical Material Testing (IL-02179-01) regarding a Troxler 3440 gauge [s/n: 24805; containing 8 mCi of Cs-137 and 40 mCi of Am-241] that was run over and crushed by an operator running a roller on a construction site at 1514 Main Street in Lombard. The RSO reported that operations had stopped and that he needed guidance to get the source rod out. At 1550 CDT, the Agency contacted the licensee for details and to provide guidance.

"The gauge user was uninjured but the gauge was run over and destroyed. At the time of the incident it was confirmed that the source rod was extended into the ground and a measurement was in process. The gauge user immediately notified personnel in the area and cordoned off the area. The gauge user then notified his RSO, who then notified Troxler (their emergency contact) and IEMA as per their emergency procedures. The RSO immediately went to the scene. He stated that he verified the security of the scene. He did not believe that the source rod was bent. The RSO stated that he was headed back to his office for a survey meter.

"Agency inspectors reviewed concerns regarding exposure from the Cs-137 source and the possibility of a leaking source with the RSO. Procedures were reviewed for surveys of the area once the gauge was removed to ensure the Cs-137 source had not become dislodged and that the source was not leaking. The Agency offered to dispatch inspectors to assist; however, the licensee had the gauge manufacturer engaged and able to respond.

"The gauge manufacturer responded to the scene at approximately 1700 CDT and confirmed the source rod was unbent and able to be shielded. Both the Am-241 and the Cs-137 sources were confirmed as present and intact. The gauge was safely repackaged into the Troxler case by Troxler personnel and the TI [Transport Index] confirmed as 0.3. This information was confirmed with pictures sent to the Agency. Troxler personnel performed surveys of the area to confirm the source was removed and that there was no contamination/leakage. Both sources (Cs-137 and Am-241) were placed into the Troxler transport container without incident. Both Troxler and the licensee performed surveys of the site prior to departing and after packaging the damaged source. At 1830, the licensee confirmed background readings at the site and the gauge was transported back to Troxler. The gauge will be leak tested and then shipped to Troxler in North Carolina for disposal.

"This matter will remain open pending receipt of leak tests, additional gauge information, documentation of disposal, and required written reports."

Illinois Item Number: IL200011

AGREEMENT STATE REPORT - THERASPHERE PROCEDURE UNDERDOSE

The following information was received via E-mail:

"On 7/15/2020, at 1340 EDT, the licensee reported that yesterday, 7/14/2020, sometime between 0915 and 0930 EDT, a male patient receiving TheraSphere treatment was underdosed by approximately 30 percent due to a leak in the delivery assembly. This was discovered around half-way through the procedure. No exposure to anyone other than the patient occurred. Contamination has been contained and removed. The prescribed activity was 5.7 GBq and dose was 150 Gy. The actual activity delivered is estimated to be 3.99 GBq and dose was 105 Gy. The patient is scheduled to return next week for follow-up treatment."

Florida Incident Number: FL20-080

A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

EN Revision Imported Date : 7/29/2020

EN Revision Text: UNAUTHORIZED USE OF A RESTRICTED RADIATION ROOM AS A TOUCHDOWN SPACE

"On July 14, 2020, at approximately 1115 MDT, the Radiation Safety Officer was notified that a restricted radiation room was used intermittently for 30-45 minute periods as a touchdown space for Billings Clinic's Internal Medicine residents. The room had not been decommissioned.

"The restricted radiation room being used was the Billings Clinic Hospital I-131 Inpatient Therapy Room (room 3501; general inpatient medical floor). This room was last used for [a 153 mCi I-131 Sodium Iodine] radiation treatment on June 21, 2017. Beginning June 4, 2020, the room began being used as a touchdown space for Internal Medicine residents. Surveys were performed on July 14, 2020 using survey meters. Wipes for removable contamination were performed on a table, two computers, phone, and the floor around the area where staff were working. All items had activity levels indistinguishable from background readings. The items were removed from the room. The room has been secured with a new lock and radiation warning signs have been reposted. The radiation signs had been removed at an unknown time between June 4, 2020 and July 14, 2020.

"The licensee is not aware of any radiation exposure as a result of this reported event."

The licensee is making this report as a deviation from 10 CFR 35.13(f) as required by reporting requirement 10 CFR 30.50(b)(1)(iii).

* * * RETRACTION ON 07/28/2020 AT 1428 EDT FROM CHRIS FITZ TO THOMAS KENDZIA * * *

This is a summary of information received from the licensee via telephone:

After discussion with NRC RIV personnel the licensee determined that this event is not reportable in accordance with 10 CFR 30.50(b)(1)(iii).

Notified R4DO (Gepford) and NMSS Events (email).